Other·November 8, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during the investigation of a complaint during an Abbreviated Standard Survey. Complaint number: CA00650595 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 36526 The inspection was limited to the specific complaint investigation and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for complaint CA00650595

F684 SS=E Quality of Care CFR(s): 483.25

F684 10/24/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to implement residents physician's orders, plan of care and policy and LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 1 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE procedures to monitor pacemakers (an artificial device for stimulating the heart muscle and regulating its contractions) and apical pulses (cardiac function [assessed by placing a stethoscope [medical instrument used for listening for body sounds]) at the left center of the chest and counting the heart beats for one minute ) for four of four sampled residents (Residents 1, 2, 3, and 4). Resident 1 had a pacemaker and orders for the apical pulse to be checked daily, but was not. Resident 1 was found unresponsive on 5/14/19 at 11:48 p.m., after having a change in condition of being diaphoretic (sweating heavily [sign of a pending heart attack]) and was pronounced deceased on 5/15/19 at 12:38 a.m. Residents 2, 3 and 4 had a pacemakers and orders for the apical pulse to be checked daily, but the licensed nurses did not know how to assess the resident's apical pulses, thus not done per the physician's order and the resident's plan of care. These deficient practices resulted in failure to follow physician orders to ensure comprehensive assessments were conducted to ensure these residents who had abnormal heart beats were assessed to ensure pacemakers were functioning properly. This non-compliance had the potential to result in the inability to identify malfunctions of the pacemakers. Findings: a. A review of Resident 1's Admission Record (Face Sheet) indicated the resident was initially admitted to the facility on 3/22/19 and most recently readmitted on 5/9/19. Resident 1's diagnoses included heart failure, atrial flutter FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 2 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ([AFL] abnormal heart rhythm), with a pacemaker. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/29/19, indicated Resident 1 had difficulty recalling and making herself understood. The MDS indicated Resident 1 was moderately impaired in cognition (thought process) for daily decisionmaking. The MDS indicated Resident 1 was total dependent of two-person physical assist for bed mobility, toilet use, and transfers. A review of Resident 1's "Pacemaker Alert" record, did not indicate the pacemaker's manufacturer, settings, and last time the pacemaker checked. A review of the facility's undated policy titled, "Pacemakers," indicated the purpose of the policy was for the facility to provide appropriate care and monitoring for residents with pacemakers. The policy indicated the information of the pacemaker should be recorded on the resident's medical record. The information should contain type of pacemaker, date of insertion, rate at which the pacemaker is set, and pacemaker test ordered by physician. The policy indicated that the nursing duties and care was to address pacemaker on the resident's care plan. A review of the National Heart, Lung, and Blood Institute (NHLBI) pacemaker article indicated that a pacemaker was a small device that was placed in the chest or abdomen to help control abnormal heart rhythms. Pacemakers also can monitor and record the heart's electrical activity and heart rhythm and should be check every three months. A review of the Healthline article indicated that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 3 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE listening to the apical pulse is the most reliable and noninvasive way to evaluate cardiac function using a stethoscope directly on the residents' left breastbone between the fifth rib. The article indicated that a pulse deficit indicated that the heart function was inadequate and was not providing enough blood to meet the needs of the body's tissues. https://www.healthline.com/health/apical-pulse. A review of Resident 1's care plan titled, "Alteration in Cardiac Status-Pacemaker," dated 5/10/19 indicated Resident 1 would not have unrecognized signs and symptoms of pacemaker malfunction for 90 days. The staff interventions included to monitor the apical pulse as ordered, monitor pacemaker site as ordered, report to physician complaints of chest pain, shortness of breath, irregular heartbeat, assess and monitor for dizziness, low/high heart rate, difficulty breathing and changes in condition and notify physician. The care plan did not indicate a set rate to monitor pulse. A review of Resident 1's care plan titled, "Resident is at Risk for Cardiac Distress Related to Pacemaker and AFL," dated 5/10/19 indicated Resident 1 would not have unrecognized signs of cardiac distress for 90 days. The staff's interventions included to monitor for headaches, chest pain, irregular pulse (heart rate that is too slow or too fast), edema (swelling), shortness of breath, elevated blood pressure, fatigue, weakness, diaphoresis (sweating, especially to an unusual degree as a symptom of disease), monitor pulse rate as ordered and report to the physician promptly. A review of Resident 1's physician orders, dated 5/9/19 indicated to monitor Resident 1's apical pulses daily for pacemaker use and for signs and symptoms of pacemaker malfunction (fail to work properly) such as changes in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 4 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE cognition level, chest pain shortness of breath, and abnormal vital signs. A review of Resident 1's Medication Administration Sheet (MAR) for the month of 5/2019 indicated there was no apical pulses recorded Resident 1 for six days (5/9/19 through 5/14/19). A review of Resident 1's physician's telephone order, dated 5/14/19 and timed at 11:48 p.m., indicated to call 911 (emergency number) to transfer Resident 1 to a higher level of care. A review of the Situation Background Assessment/evaluation Request/management Plan ([SBAR] internal change of condition form), dated 5/14/19 and timed at 11:48 p.m., indicated Resident 1 was found unresponsive (unconscious [lack of the ability to notice or respond to stimuli in the environment]). The SBAR indicated Resident 1 had a blood pressure (BP) of 142/78 (Normal Reference Range [NRR] BP 90/60 to 120/80), respirations 18 breaths per minute (BPM [NRR 12 to 18 BPM]), and a pulse of 74 beats per minute ([NRR pulse of 60 to 100 beats per minute). The SBAR indicated the physician was notified on 5/15/19 at 1:20 a.m., and Resident 1's responsible party (RP) on 5/15/19 at 12 a.m., [sic]. However the review of the Licensed Progress notes during the same time indicated that Resident 1 was unresponsive and the staff was unable to obtain a BP reading on Resident 1. A review of a Licensed Progress note, dated 5/15/19 and timed at 11:48 p.m., [sic] indicated Resident 1 was found unresponsive and the staff was unable to obtain a BP reading. The nurse's note indicated a respiratory therapist ([RT] certified medical professional who specializes in providing healthcare for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 5 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE lungs) was called to Resident 1's bedside and cardiopulmonary resuscitation ([CPR] C=cardio [heart] P=pulmonary [lung] R=resuscitation [chest compression and artificial breathing are used to maintain blood circulation to the brain]) was initiated unsuccessfully, 911 was called and arrived at 11:55 p.m. The nurse's note indicated Resident 1 was pronounced deceased at 12:38 a.m., on 5/15/19. A review of a paramedic run sheet indicated an emergency response was dispatched on 5/14/19 at 11:59 p.m. and arrived at the facility on 5/15/19 at 12:03 a.m. The run sheet indicated that upon arrival, Resident 1 was found unresponsive and pulseless with no signs of trauma; active bleeding; abdominal distention and/or any deformities. Resident 1 was pronounced deceased on 5/15/19 at 12:38 a.m. by the paramedics after unsuccessful CPR. A review of Resident 1's death certificate indicated Resident 1 died on 5/15/19 at 12:38 a.m., and the death certificate indicated cardiopulmonary arrest (sudden stop in effective and normal blood circulation due to failure of the heart to pump blood) was listed as Resident 1's primary cause of death and asystole (complete stop of heart activity) listed as the secondary cause. On 8/15/19 at 4:44 p.m., during an interview, Resident 1's RP stated on 5/14/19 at approximately 10 p.m., she left the facility and later that night received a called from the facility's staff stating Resident 1 was not feeling well, was hot and sweaty and requesting a fan. On 10/7/19 at 3:22 p.m., during an interview, Registered Nurse 2 (RN 2) stated on 5/14/19 at approximately 11:20 p.m., Resident 1 told her that she was hot and sweaty and asked to have FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 6 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a fan placed facing her. RN 2 stated she went to check on Resident 1 and found her unresponsive and with a faint pulse. b. A review of Resident 2's Admission Record indicated the resident was initially admitted to the facility on 9/13/14 and most recently readmitted on 9/21/17. Resident 2's diagnoses included, high blood pressure and heart failure with a pacemaker. A review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/8/19, indicated Resident 2 was moderately impaired in cognition for daily decision-making. The MDS indicated Resident 2 was totally dependent of a one-person physical assist for bed mobility, toilet use, and transfers. A review of Resident 2's "Pacemaker Alert" record indicated the pacemaker's setting was 60-100 beats per minute and did not indicate the cardiologist (specialist in the study or treatment of the heart) name and phone number. A review of Resident 2's care plan titled, "Alteration in Cardiac Status-Pacemaker," revised on 2/20/18 indicated Resident 2 would not have unrecognized signs and symptoms of the pacemaker malfunction for 90 days. The staffs' interventions included to monitor the apical pulse as ordered, monitor site as ordered, report to physician complaints of chest pain, shortness of breath, irregular heartbeat, assess and monitor for dizziness, low/high heart rate, difficulty breathing and changes in condition and notify physician. The care plan did not indicate a set rate to monitor Resident 2's pulse. A review of Resident 2's physician orders, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 7 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dated 9/21/17, indicated to monitor apical pulses daily for pacemaker use, monitor for signs and symptoms of the pacemaker malfunction such as changes in cognition level, chest pain shortness of breath, and abnormal vital signs. A review of Resident 2's MAR for the month of 8/2019 indicated there was no apical pulses recorded for six days (8/3/19 through 8/9/19). On 8/16/19 at 1:18 p.m., during an interview and observation, Registered Nurse 1 (RN 1) was observed taking Resident 2's apical pulse on the left wrist [sic] for one minute. RN 1 stated that apical pulses are recorded daily on the resident's MAR sheet. During the concurrent interview and observation, Resident 2 stated that the staff do not normally check his heart rate on a daily basis. On 8/16/19 at 1:25 p.m., during an interview and review of Resident 2's MAR for the month of 8/2019, LVN 3 stated she forgot to document on Resident 2's MAR the resident's daily apical pulses. LVN 3 stated apical pulses should be monitor and documented daily as indicated in the care plan and the physician's orders. c. A review of Resident 3's Admission Record indicated Resident 3 was initially admitted to the facility on 1/2/18 and most recently readmitted on 9/6/18. Resident 3's diagnoses included heart failure, coronary artery disease ([CAD] the arteries supplying blood to the heart become hard and narrow), angina pectoris (severe chest pain) and a pacemaker. A review of Resident 3's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/8/19, indicated Resident 3 was moderately impaired in cognition for daily decision-making. The MDS FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 8 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated Resident 3 was totally dependent on a one-person physical assist for bed mobility, toilet use, and transfers. A review of Resident 3's "Pacemaker Alert" record indicated the pacemaker's setting was 60-120 beats per minute, but did not indicate the cardiologist's phone number and pacemaker's serial number. A review of Resident 3's care plan titled, "Alteration in Cardiac Status-Pacemaker," dated 1/2/18 indicated Resident 3 would not have unrecognized signs and symptoms of pacemaker malfunction for 90 days. The staffs' interventions included to monitor the apical pulse as ordered, monitor site as ordered, report to physician complaints of chest pain, shortness of breath, irregular heartbeat, assess and monitor for dizziness, low/high heart rate, difficulty breathing and changes in condition and notify physician. A review of Resident 3's physician orders, dated 9/6/18 indicated to monitor apical pulses daily for pacemaker use, monitor for signs and symptoms of pacemaker malfunction, such as changes in cognition level, chest pain shortness of breath, and abnormal vital signs. A review of Resident 3's MAR for the month of 8/2019 (8/1/19 through 8/16/19 [15 days]) did not have documented evidence of daily apical pulses recorded for Resident 3. On 8/16/19 at 12:47 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she did not check Resident 3's apical pulses during her shift. On 8/16/19 at 12:51 p.m., during an interview and observation, LVN 2 stated that apical pulse checks were done daily and documented on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 9 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the resident's MAR. LVN 2 stated the apical pulse was checked on resident's wrist for one minute using two fingers [sic]. d. A review of Resident 4's Admission Record indicated the resident was initially admitted to the facility on 10/21/17 and most recently readmitted on 6/10/19. Resident 4's diagnoses included high blood pressure and heart failure with a pacemaker. A review of Resident 4's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 7/11/19, indicated Resident 4 had no memory problems and some difficulty in modified independence for cognitive skills for daily decision-making in new situations. The MDS indicated Resident 4 was totally dependent of a one-person physical assist for bed mobility, toilet use, and transfers. A review of Resident 4's "Pacemaker Alert" record indicted the pacemaker's setting was 60 -100 beats per minute, and did not indicate the cardiologist phone number and the pacemaker manufacturer. A review of Resident 4's care plan titled, "Alteration in Cardiac Status-Pacemaker," revised on 2/2019 indicated that Resident 4 would not have unrecognized signs and symptoms of pacemaker malfunction for 90 days. The staffs' interventions included to monitor for apical pulse as ordered, monitor site as ordered, report to physician complaints of chest pain, shortness of breath, irregular heartbeat, assess and monitor for dizziness, low/high heart rate, difficulty breathing and changes in condition and notify physician. The care plan indicated a set rate of 60-100 bpm. A review of Resident 4's physician orders, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 10 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dated 6/10/19, indicated to monitor apical pulses daily for pacemaker use, monitor for signs and symptoms of pacemaker malfunction such as changes in cognition level, chest pain shortness of breath, and abnormal vital signs. On 8/16/19 at 1:15 p.m., during an interview, Resident 4 stated the nurses would check his heart rate using a machine that was placed on his finger (pulse oximeter [a sensor device is placed on a thin part of the patient's body, usually a fingertip or earlobe to monitor oxygen level). Resident 4 stated that his heart rate was not check regularly. On 8/16/19 at 1:33 p.m., during an interview and record review, LVN 4 stated she was sorry that she had forgotten to document the daily apical pulses for the month of 8/2019 for Resident 3. LVN 4 stated apical pulses are checked with a stethoscope placed on the residents' right side of the chest for one minute and are done daily and documented in the resident's MARs. LVN 4 stated the staff does not document unless there was a change in the resident's condition. On 8/16/19 at 1:48 p.m., during an interview, once it was identified that the nurses were not knowledgeable of how to assess apical pulses the Director of Nurses (DON) stated there had not been any in-services conducted regarding the monitoring of pacemakers and how to check apical pulses. On 8/16/19 at 2:13 p.m., during an interview and record review in the presence of the Administrator (ADM), RN Consultant (RNC), social services director (SSD), the director of nurses (DON) stated the staff should be assessing and documenting the residents apical pulses as indicated in the residents care plan and per the physician orders. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 11 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's undated policy and procedure titled, "The Resident Care Plan," indicated that it was the responsibility of the DON to ensure each professional involved in the care of the resident was aware of the written plan of care, including its location, the current problems of the resident and the goals and objectives. The objective of the policy was to ensure individualized nursing care plan was conducted to promote continuity of resident care. A review of the facility's policy titled, "Physician Orders and Telephone Orders," dated 1/2004 indicated that all orders must be specific and complete with all necessary details to carry out the prescribed order without any questions.

F689 SS=E Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 10/24/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 12 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on observation, interview and record review, the facility fail to implement residents' physician's orders, plan of care and policy and procedures to monitor pacemakers (an artificial device for stimulating the heart muscle and regulating its contractions) and care plans for apical pulses (cardiac function that is completed by placing a stethoscope at the left center of the chest below nipple line and counting for one minute) for four of four residents (Residents 1, 2, 3, and 4). a. Resident 1, who had a pacemaker, had orders for apical pulse checks daily. Resident 1 was found unresponsive on 5/14/19 11:48 p.m., and was pronounced deceased on 5/15/19 at 12:38 a.m. b. Resident 2 who had a pacemaker, had orders for apical pulse checks daily. c. Resident 3 who had a pacemaker, had orders for apical pulse checks daily. d. Resident 4 who had a pacemaker, had orders for apical pulse checks daily. These deficient practices resulted in failure to follow physician orders to ensure comprehensive assessments were conducted to ensure these residents who had abnormal heart beats were assessed to ensure pacemakers were functioning properly. This non-compliance had the potential to result in the inability to identify malfunctions of the pacemakers. Findings: a. A review of Resident 1's Admission Record (Face Sheet) indicated the resident was initially FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 13 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE admitted to the facility on 3/22/19 and most recently readmitted on 5/9/19. Resident 1's diagnoses included heart failure, atrial flutter ([AFL] abnormal heart rhythm), with a pacemaker. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/29/19, indicated Resident 1 had difficulty recalling and making herself understood. The MDS indicated Resident 1 was moderately impaired in cognition (thought process) for daily decisionmaking. The MDS indicated Resident 1 was total dependent of two-person physical assist for bed mobility, toilet use, and transfers. A review of Resident 1's "Pacemaker Alert" record, did not indicate the pacemaker's manufacturer, settings, and last time the pacemaker checked. A review of the facility's undated policy titled, "Pacemakers," indicated that the purpose of the policy was for the facility to provide appropriate care and monitoring for residents with pacemaker. The policy indicated that the information of the pacemaker should be recorded on the resident's medical record. The information should contain type of pacemaker, date of insertion, rate at which the pacemaker is set, and pacemaker test ordered by physician. The policy indicated that the nursing duties and care was to address pacemaker on the resident's care plan. A review of the National Heart, Lung, and Blood Institute (NHLBI) pacemaker article indicated that a pacemaker is a small device that is placed in the chest or abdomen to help control abnormal heart rhythms. Pacemakers also can monitor and record your heart's electrical activity and heart rhythm and should FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 14 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE be check every three months. A review of Resident 1's care plan titled, "Alteration in Cardiac Status-Pacemaker," dated 5/10/19 indicated Resident 1 would not have unrecognized signs and symptoms of pacemaker malfunction for 90 days. The staff interventions included to monitor for apical pulse as ordered, monitor site as ordered, report to physician complaints of chest pain, shortness of breath, irregular heartbeat, assess and monitor for dizziness, low/high heart rate, difficulty breathing and changes in condition and notify physician. The care plan did not indicate a set rate to monitor pulse. A review of Resident 1's care plan titled, "Resident is at Risk for Cardiac Distress Related to Pacemaker and AFL," dated 5/10/19 indicated Resident 1 would not have unrecognized signs of cardiac distress for 90 days. The staff's interventions included to monitor for headaches, chest pain, irregular pulse (heart rate that is too slow or too fast), edema (swelling), shortness of breath, elevated blood pressure, fatigue, weakness, diaphoresis (sweating, especially to an unusual degree as a symptom of disease), monitor pulse rate as ordered and report to the physician promptly. A review of Resident 1's physician orders, dated 5/9/19 indicated to monitor Resident 1's apical pulses daily for pacemaker use and for signs and symptoms of pacemaker malfunction (fail to work properly) such as changes in cognition level, chest pain shortness of breath, and abnormal vital signs. A review of Resident 1's Medication Administration Sheet (MAR) indicated there was no apical pulses recorded for six days (5/9/19 through 5/14/19). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 15 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's physician's telephone order, dated 5/14/19 and timed at 11:48 p.m., indicated to call 911 (emergency number) to transfer Resident 1 to a higher level of care. A review of the Situation Background Assessment/evaluation Request/management Plan (SBAR), dated 5/14/19 and timed at 11:48 p.m., indicated Resident 1 was found unresponsive (unconscious [lack of the ability to notice or respond to stimuli in the environment]). The SBAR indicated Resident 1 had a blood pressure (BP) of 142/78 (Normal Reference Range [NRR] BP 90/60 to 120/80), respirations 18 breaths per minute (BPM [NRR 12 to 18 BPM]), and a pulse of 74 beats per minute ([NRR pulse of 60 to 100 beats per minute). The SBAR indicated the physician was notified on 5/15/19 at 1:20 a.m., and Resident 1's responsible party (RP) on 5/15/19 at 12 a.m., [SIC] however the review of the Licensed Progress notes indicated that Resident 1 was unresponsive and staff was unable to obtain a BP reading. A review of the Licensed Progress notes, dated 5/15/19, and timed at 11:48 p.m., [SIC] indicated Resident 1 was found unresponsive and the staff was unable to obtain a BP reading. The nurse's note indicated a respiratory therapist ([RT] certified medical professional who specializes in providing healthcare for the lungs) was called to Resident 1's bedside and cardiopulmonary resuscitation ([CPR] C=cardio [heart] P=pulmonary [lung] R=resuscitation [chest compression and artificial breathing are used to maintain blood circulation to the brain], 911 called and arrived at 11:55 p.m. the nurse's note indicated that Resident 1 was pronounced deceased at 12:38 a.m., on 5/15/19. A review of Resident 1's death certificate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 16 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated Resident 1 died on 5/15/19 at 12:38 a.m., and the death certificate indicated cardiopulmonary arrest (sudden stop in effective and normal blood circulation due to failure of the heart to pump blood) was listed as Resident 1's cause of death and asystole (complete stop of heart activity) listed as secondary cause. On 8/15/19 at 4:44 p.m., during an interview, Resident 1's RP stated that on 5/14/19 at approximately at 10 p.m., she left the facility and later that night received a called from the facility's staff stating Resident 1 was not feeling well, was hot and sweaty and requesting a fan. On 10/7/19 at 3:22 p.m., during an interview, Registered Nurse 2 (RN 2) stated on 5/14/19 at approximately 11:20 p.m., Resident 1 called her stating that she was hot and sweaty and asked to have a fan placed facing her. RN 2 stated she went to check on Resident 1 and found her unresponsive and with a faint pulse. the RN 2 stated that the vital signs that she recorded on the SBAR, were the vital signs she obtained from Resident 1 when she found her in her room unresponsive. b. A review of Resident 2's Admission Record indicated the resident was initially admitted to the facility on 9/13/14 and most recently readmitted on 9/21/17. Resident 2's diagnoses included, high blood pressure and heart failure with a pacemaker. A review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/8/19, indicated Resident 2 was moderately impaired in cognition for daily decision-making. The MDS indicated Resident 2 was totally dependent of a one-person physical assist for bed mobility, toilet use, and transfers. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 17 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 2's "Pacemaker Alert" record indicted the pacemaker's setting was 60 -100 beats per minute, and did not indicate the cardiologist (specialist in the study or treatment of the heart) name and phone number. A review of Resident 2's care plan titled, "Alteration in Cardiac Status-Pacemaker," revised on 2/20/18 indicated that Resident 2 would not have unrecognized signs and symptoms of pacemaker malfunction for 90 days. The staffs' interventions included to monitor for apical pulse as ordered, monitor site as ordered, report to physician complaints of chest pain, shortness of breath, irregular heartbeat, assess and monitor for dizziness, low/high heart rate, difficulty breathing and changes in condition and notify physician. The care plan did not indicate a set rate to monitor pulse. A review of Resident 2's physician orders, dated 9/21/17, indicated to monitor apical pulses daily for pacemaker use, monitor for signs and symptoms of pacemaker malfunction such as changes in cognition level, chest pain shortness of breath, and abnormal vital signs. A review of Resident 2's MAR sheet indicated there was no apical pulses recorded for six days (8/3/19 through 8/9/19). On 8/16/19 at 1:18 p.m., during an interview and observation, Registered Nurse 1 (RN 1) was observed taking Resident 2's apical pulse on left wrist [SIC] for one minute. RN 1 stated that apical pulses are recorded daily on the resident's MAR sheet. During the concurrent interview and observation, Resident 2 stated that the staff do not normally check his heart rate on a daily FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 18 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE basis. On 8/16/19 at 1:25 p.m., during an interview and review of Resident 2's MAR for 8/2019, LVN 3 stated she forgot to document on Resident 2's MAR sheet the resident's daily apical pulses. LVN 3 stated apical pulses should be monitor and documented daily as indicated in the care plan and the physician's orders. c. A review of Resident 3's Admission Record indicated Resident 3 was initially admitted to the facility on 1/2/18 and most recently readmitted on 9/6/18. Resident 3's diagnoses included heart failure, coronary artery disease ([CAD] the arteries supplying blood to the heart become hard and narrow), angina pectoris (severe chest pain) and a pacemaker. A review of Resident 3's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/8/19, indicated Resident 3 was moderately impaired in cognition for daily decision-making. The MDS indicated Resident 3 was totally dependent a one-person physical assist for bed mobility, toilet use, and transfers. A review of Resident 3's "Pacemaker Alert" record indicated the pacemaker's setting was 60-120 beats per minute, but did not indicate the cardiologist phone number and pace maker serial number. A review of Resident 3's care plan titled, "Alteration in Cardiac Status-Pacemaker," dated 1/2/18 indicated Resident 3 would not have unrecognized signs and symptoms of pacemaker malfunction for 90 days. The staffs' interventions included to monitor for apical pulse as ordered, monitor site as ordered, report to physician complaints of chest pain, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 19 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE shortness of breath, irregular heartbeat, assess and monitor for dizziness, low/high heart rate, difficulty breathing and changes in condition and notify physician. A review of Resident 3's physician orders, dated 9/6/18 indicated to monitor apical pulses daily for pacemaker use, monitor for signs and symptoms of pacemaker malfunction, such as changes in cognition level, chest pain shortness of breath, and abnormal vital signs. A review of Resident 3's MAR for the month of 8/2019 (8/1/19 through 8/16/19 [15 days]) did not have documented daily apical pulses. On 8/16/19 at 12:47 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she did not check Resident 3's apical pulses during her shift. On 8/16/19 at 12:51 p.m., during an interview and observation, LVN 2 stated that apical pulse checks were done daily and documented on the MAR sheets. LVN 2 stated that apical pulse was checked on resident's wrist for one minute using two fingers. d. A review of Resident 4's Admission Record indicated the resident was initially admitted to the facility on 10/21/17 and most recently readmitted on 6/10/19. Resident 4's diagnoses included, high blood pressure and heart failure with a pacemaker. A review of Resident 4's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 7/11/19, indicated Resident 4 had no memory problems and some difficulty in modified independence for cognitive skills for daily decision-making in new situations. The MDS indicated Resident 4 was totally dependent of a one-person physical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 20 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assist for bed mobility, toilet use, and transfers. A review of Resident 4's "Pacemaker Alert" record indicted the pacemaker's setting was 60 -100 beats per minute, and did not indicate the cardiologist phone number and the pacemaker manufacturer. A review of Resident 4's care plan titled, "Alteration in Cardiac Status-Pacemaker," revised on 2/2019 indicated that Resident 4 would not have unrecognized signs and symptoms of pacemaker malfunction for 90 days. The staffs' interventions included to monitor for apical pulse as ordered, monitor site as ordered, report to physician complaints of chest pain, shortness of breath, irregular heartbeat, assess and monitor for dizziness, low/high heart rate, difficulty breathing and changes in condition and notify physician. The care plan indicated a set rate of 60-100 bpm. A review of Resident 2's physician orders, dated 6/10/19, indicated to monitor apical pulses daily for pacemaker use, monitor for signs and symptoms of pacemaker malfunction such as changes in cognition level, chest pain shortness of breath, and abnormal vital signs. On 8/16/19 at 1:15 p.m., during an interview, Resident 4 stated the nurses check his heart rate using a machine that was placed on his finger. Resident 4 stated that his heart rate was not check regularly. On 8/16/19 at 1:33 p.m., during an interview and record review, LVN 4 stated that she was sorry that she forgot to document the daily apical pulses for the month of 8/2019 for Resident 3. LVN 4 stated that apical pulses are checked with a stethoscope (medical instrument for listening to the heart or breath FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 21 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE sounds) placed on the residents' right side of the chest for one minute and are done daily and documented in the resident's MAR sheet. LVN 4 stated the staff does not document unless there was a change in the resident's condition. On 8/16/19 at 1:48 p.m., during an interview, Director of Nurses (DON) stated that no inservice regarding the monitor of pacemakers and how to check for apical pulses had been conducted. On 8/16/19 at 2:13 p.m., during an interview and record review in the presence of the Administrator (ADM), RN Consultant (RNC), social services director (SSD), the director of nurses (DON) stated the staff should be documenting the apical pulses as indicated in the residents care plan and per the physician orders. A review of the facility's undated policy and procedure titled, "The Resident Care Plan," indicated that it was the responsibility of the DON to ensure each professional involved in the care of the resident was aware of the written plan of care, including its location, the current problems of the resident and the goals and objectives. The objective of the policy was to ensure individualized nursing care plan was conducted to promote continuity of resident care. A review of the facility's policy titled, "Physician Orders and Telephone Orders," dated 1/2004 indicated that all orders must be specific and complete with all necessary details to carry out the prescribed order without any questions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 22 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F726 Competent Nursing Staff CFR(s): 483.35(a)(3)(4)(c)

F726 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10/24/2019 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to implement its policy to ensure the nursing staff was competent and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 23 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE possessed skills to follow and implement physician orders and residents' plan of care for four of four sampled residents (Resident 1, 2, 3, and 4). These deficient practices resulted in the facility's failure to follow residents' care plans and physician orders to monitor apical pulses (cardiac function that is completed by placing a stethoscope at the chest and counting the heart beats for one minute) for early detection of pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions) malfunctions, and had the potential of malfunction of pacemaker not being identified that could lead to death. Findings: a. A review of Resident 1's Admission Record (Face Sheet) indicated the resident was initially admitted to the facility on 3/22/19 and most recently readmitted on 5/9/19. Resident 1's diagnoses included heart failure, atrial flutter ([AFL] abnormal heart rhythm), with a pacemaker. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/29/19, indicated Resident 1 had difficulty recalling and making herself understood. The MDS indicated Resident 1 was moderately impaired in cognition (thought process) for daily decisionmaking. The MDS indicated Resident 1 was total dependent of two-person physical assist for bed mobility, toilet use, and transfers. A review of Resident 1's care plan titled, "Alteration in Cardiac Status-Pacemaker," dated 5/10/19 indicated Resident 1 would not have unrecognized signs and symptoms of pacemaker malfunction for 90 days. The staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 24 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE interventions included to monitor for apical pulse as ordered, monitor site as ordered, report to physician complaints of chest pain, shortness of breath, irregular heartbeat, assess and monitor for dizziness, low/high heart rate, difficulty breathing and changes in condition and notify physician. A review of Resident 1's physician orders, dated 5/9/19 indicated to monitor Resident 1's apical pulses daily for pacemaker use and for signs and symptoms of pacemaker malfunction (fail to work properly) such as changes in cognition level, chest pain shortness of breath, and abnormal vital signs. b. A review of Resident 2's Admission Record indicated the resident was initially admitted to the facility on 9/13/14 and most recently readmitted on 9/21/17. Resident 2's diagnoses included, high blood pressure and heart failure with a pacemaker. A review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/8/19, indicated Resident 2 was moderately impaired in cognition for daily decision-making. The MDS indicated Resident 2 was totally dependent of a one-person physical assist for bed mobility, toilet use, and transfers. A review of Resident 2's care plan titled, "Alteration in Cardiac Status-Pacemaker," revised on 2/20/18 indicated that Resident 2 would not have unrecognized signs and symptoms of pacemaker malfunction for 90 days. The staffs' interventions included to monitor for apical pulse as ordered, monitor site as ordered, report to physician complaints of chest pain, shortness of breath, irregular heartbeat, assess and monitor for dizziness, low/high heart rate, difficulty breathing and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 25 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE changes in condition and notify physician. The care plan did not indicate a set rate to monitor pulse. A review of Resident 2's physician orders, dated 9/21/17, indicated to monitor apical pulses daily for pacemaker use, monitor for signs and symptoms of pacemaker malfunction such as changes in cognition level, chest pain shortness of breath, and abnormal vital signs. On 8/16/19 at 1:18 p.m., during an interview and observation, Registered Nurse 1 (RN 1) was observed taking Resident 2's apical pulse on left wrist for one minute. RN 1 stated that apical pulses are recorded daily on the resident's MAR sheet. [SIC] During the concurrent interview and observation, Resident 2 stated the staff do not normally check his heart rate on a daily basis. On 8/16/19 at 1:25 p.m., during an interview and review of Resident 2's MAR for 8/2019, LVN 3 stated she forgot to document on Resident 2's MAR the resident's daily apical pulses. LVN 3 stated apical pulses should be monitor and documented daily as indicated per the care plan and the physician's orders. c. A review of Resident 3's Admission Record indicated Resident 3 was initially admitted to the facility on 1/2/18 and most recently readmitted on 9/6/18. Resident 3's diagnoses included heart failure, coronary artery disease ([CAD] the arteries supplying blood to the heart become hard and narrow), angina pectoris (severe chest pain) and a pacemaker. A review of Resident 3's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/8/19, indicated Resident 3 was moderately impaired in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 26 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE cognition for daily decision-making. The MDS indicated Resident 3 was totally dependent a one-person physical assist for bed mobility, toilet use, and transfers. A review of Resident 3's care plan titled, "Alteration in Cardiac Status-Pacemaker," dated 1/2/18 indicated Resident 3 would not have unrecognized signs and symptoms of pacemaker malfunction for 90 days. The staffs' interventions included to monitor for apical pulse as ordered, monitor site as ordered, report to physician complaints of chest pain, shortness of breath, irregular heartbeat, assess and monitor for dizziness, low/high heart rate, difficulty breathing and changes in condition and notify physician. A review of Resident 3's physician orders, dated 9/6/18 indicated to monitor apical pulses daily for pacemaker use, monitor for signs and symptoms of pacemaker malfunction, such as changes in cognition level, chest pain shortness of breath, and abnormal vital signs. On 8/16/19 at 12:47 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she did not check Resident 3's apical pulses during her shift. On 8/16/19 at 12:51 p.m., during an interview and observation, LVN 2 stated that apical pulse checks were done daily and documented on the MAR. LVN 2 stated that apical pulse was checked on resident's wrist for one minute using two fingers. d. A review of Resident 4's Admission Record indicated the resident was initially admitted to the facility on 10/21/17 and most recently readmitted on 6/10/19. Resident 4's diagnoses included, high blood pressure and heart failure with a pacemaker. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 27 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 4's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 7/11/19, indicated Resident 4 had no memory problems and some difficulty in modified independence for cognitive skills for daily decision-making in new situations. The MDS indicated Resident 4 was totally dependent of a one-person physical assist for bed mobility, toilet use, and transfers. A review of Resident 4's care plan titled, "Alteration in Cardiac Status-Pacemaker," revised on 2/2019 indicated that Resident 4 would not have unrecognized signs and symptoms of pacemaker malfunction for 90 days. The staffs' interventions included to monitor for apical pulse as ordered, monitor site as ordered, report to physician complaints of chest pain, shortness of breath, irregular heartbeat, assess and monitor for dizziness, low/high heart rate, difficulty breathing and changes in condition and notify physician. The care plan indicated a set rate of 60-100 bpm. A review of Resident 4's physician orders, dated 6/10/19, indicated to monitor apical pulses daily for pacemaker use, monitor for signs and symptoms of pacemaker malfunction such as changes in cognition level, chest pain shortness of breath, and abnormal vital signs. On 8/16/19 at 1:15 p.m., during an interview, Resident 4 stated the nurses check his heart rate using a machine that was placed on his finger. Resident 4 stated his heart rate was not check regularly. On 8/16/19 at 1:33 p.m., during an interview and record review, LVN 4 stated that she was sorry that she forgot to document the daily apical pulses for the month of 8/2019 for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 28 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 3. LVN 4 stated that apical pulses are checked with a stethoscope (medical instrument for listening to the heart or breath sounds) placed on the residents' right side of the chest for one minute and are done daily and documented in the resident's MAR sheet. LVN 4 stated the staff does not document unless there was a change in the resident's condition. On 8/16/19 at 1:48 p.m., during an interview, Director of Nurses (DON) stated that no inservice regarding the monitor of pacemakers and how to check for apical pulses had been conducted. On 8/16/19 at 2:13 p.m., during an interview and record review in the presence of the Administrator (ADM), RN Consultant (RNC), social services director (SSD), the DON stated the staff should be documenting the apical pulses as indicated in the residents care plan and per the physician orders. A review of the facility's undated policy and procedure titled, "The Resident Care Plan," indicated that it was the responsibility of the DON to ensure each professional involved in the care of the resident was aware of the written plan of care, including its location, the current problems of the resident and the goals and objectives. A review of the facility's undated policy titled, "Pacemakers," indicated that the purpose of the policy was for the facility to provide appropriate care and monitoring for residents with pacemaker. The policy indicated that the information of the pacemaker should be recorded on the resident's medical record. The information should contain type of pacemaker, date of insertion, rate at which the pacemaker is set, and pacemaker test ordered by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 29 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555069 (X3) DATE SURVEY COMPLETED 10/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTERN CONVALESCENT HOSPITAL 2190 W Adams Blvd Los Angeles, CA 90018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE physician. The policy indicated that the nursing duties and care was to address pacemaker on the resident's care plan. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8JQ11 Facility ID: CA970000054 If continuation sheet 30 of 30